Communication skills in medicine

Where art meets science

Dr Sanjay Suri

Consultant Paediatrician

Rotherham NHS Foundation Trust

Rotherham

2014

Doctors KnowledgePerceived powerHealthResponsibilitiesMiddle class

PatientsBeliefsVulnerableFrightenedUnwellRightsAny class

What is communication?Latin Communicare = (to have something in) common

Oxford English Dictionary

“The exchange of information between individuals,

by means of speaking, writing or using a common

system of signs or behaviour”

Microsoft Encarta Dictionary 2001

The climate we live in…

Complex illnesses and treatmentsHealthcare teamsIncreased patient expectationsBlame and Complaint cultureLitigationDiversityResource limitation

Myths about communication skillsExperience Observing seniorsPersonality traitKnowing your subjectCommand of EnglishArticulateResponding to verbal cuesBeing nice Giving time

Consultation skills of young doctors

Patients preferred those who Introduced themselves Were sympathetic Appeared self-confident Listened to them Responded to verbal cues Asked precise and simple questions Did not repeat themselves

Maguire P et al 1989Consultation skills of young doctors

Quote“Time is a great teacher but unfortunately it

kills all its pupils”

Hector BerliozFrench composer1803-1869

Experience is……

…the ability to commit the same

mistakes with increasing confidence

How long (on an average) before a doctor interrupts the

patient?

Primary care 22 seconds

Secondary care92 seconds

Copyright ©2002 BMJ Publishing Group Ltd.

Langewitz, W. et al. BMJ 2002;325:682-683

Spontaneous talking time

What do patients want ?

Give me 5!Eye contact

“Nothing worse than not getting eye contact from the doctor”

Partnership“Patients want to be people that doctors do things with rather than do things to”

Communication“Patients and doctors may have trouble understanding one another”

Time“If one wish could be granted, it is for more time with the doctor”

Appointments“Patients want to see their doctor within a reasonable time”

[Mike Stone Director Patients Association Harrow BMJ 2003;326:1294(14 June)]

Listen to the patientThey are

telling you the

diagnosis !!

GMC“Listening and good communication skillswere widely seen not only as a usefulmeans to improve the patient experience but also assisting diagnosis and patientconcordance”

Setting standards : Views of members of the public and doctors on the standard of care and practice they expect of doctors

Alison ChisholmLiz CairncrossJanet Askham

Picker Institute Europe 2006

Why bother?

Benefits to patientsPatients problems are identified more

accuratelyAdherence to treatment instructions is

improvedMay improve health outcomes – better

emotional health, symptom resolution and pain control

Likely to reduce the incidence of clinical error

Benefits to professionalsMay relieve pressure in an emotionally

demanding professionJob satisfaction may be enhancedPatients are less likely to complain Reduced likelihood of being sued

Evidence for benefits The longer the doctor waits before interrupting the

patient, the more likely they are to discover the full spread of issues ( Marvel 1999)

Picking up and responding to patient cues shortens rather than lengthens the visits (Levinson 2000)

Asking patients to repeat in their own words increased retention by 30% (Bertakis 1977)

Patients who are viewed as partners and informed of treatment rationales are more adherent to treatment ( Schulman 1979)

Communication was the most important factor in compliance (McLane 1995)

What stops us?

Barriers

BarriersLack of skillsInadequate knowledge & trainingUndervaluing the importance of communicatingLack of timeUncomfortable topics (e.g. child protection)Lack of confidence

BarriersTiredness/ Stress

Language barriers (e.g. overseas doctors/patients)

Personality and class differences between doctors and patients

Concerns regarding confidentiality

Lack of knowledge of illness/condition

How to communicate better

Kalamazoo consensus statementEssential components of a consultation•Building the doctor–patient relationship•Opening the discussion and gathering information•Understanding the patient’s perspective•Sharing information•Reaching agreement on treatment•Closure

Building the relationshipReduces anxiety and distressImproves willingness to engage

Break the iceOffer choice to see them alone firstWhen the child does not speak…..Rapport building

Opening the discussionOpening statement eg

What can I do for you? What are your concerns about Sam?

How to involve children…Eye contactPatienceUse nameOpen posture

Gathering informationListening skills

show you are listeningnonverbal behaviourclarifying summarising

ICE Ideas Concerns Expectations

Rapport building

Company + privacyDistractionPraiseExplanationReassurance

Sharing information

“Frame” your explanationTell them what you are about to tell themFind out what they know alreadyBuild on ICEUse appropriate languageUse visual aids

Sharing informationCheck understanding

Eye contact Asking questions Forward posture

Offer other sources of informationLettersLeafletsInternet

Closing the consultation

Summarising an action planSafety netting Tell them what happens next

Sharing bad news

PreparationAre you the right person to give the news? Environment--ideally a quiet, comfortable, private

roomMinimize interruptionsDo not appear rushedKnow as much about the case as you can start. Consider who should be there. Consider an

interpreter. Consider whether there may be cultural attitudesIntroduce any members of the team or studentsBrace yourself for an emotional task!

Sharing the newsExplore what is known by the patient/family

already. Give information with honesty but sensitivityTry to use simple language Take care with prognosticationDo not take all hope away--find some reason to be

optimistic. Allow time for questions. Listen to what the parents say.Don’t be worried by periods of silence.

Sharing the newsRecognize and cope with family denialDo not impose the truth but if the patient asks,

do not lie. Avoid false reassurances. Acknowledge that dealing with uncertainty is

often harder than knowing the diagnosis. Try not to let your own opinions interfere even if

parents push you to make a decision for themGive the parents sufficient information to be able

to make any decisions with you.

Sharing the newsRecognize and acknowledge the feelings the parents

or patient may have, such as anger. Show empathy but do not lose control. Try not to overload parents with too much

information on the first meeting. Don’t stay too long. Closure can be difficult--make

sure you have arranged follow-up---then leave the room,

Leaving a nurse with the parents for a period of timeMost consultations last 15-30 mins – some may be

longer

Follow upArrange a review appointment relatively soonProvide written information if available (patient-information

leaflets, support-group literature). Suggest writing down any questions they think ofDocument in the notes what information the parents have

been given and who was present. At review appointments, update the news, for instance if

further test results are available. There may be ongoing bad news to communicate.. Liaise with the primary healthcare team (GP, health visitor)

and any other relevant professionals. Consider debriefing for the staff involved. Bereavement counselling

Any questions?